Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Terrace during CMS and state inspections, most recent first.
A resident with dementia, poor safety awareness, and a known history of elopement and exit-seeking behavior was not adequately supervised despite repeated agitation and attempts to reach the elevator. Staff, including an LPN, CNA, social services, and activity staff, intermittently redirected and "watched" the resident but did not provide continuous 1:1 supervision. While the LPN and CNA were performing wound care on another resident, the resident moved down a hallway, accessed an alarmed stairwell door, descended interior stairs, exited a second alarmed door, and traveled across the parking lot and a busy four-lane street to a nearby apartment complex, where the resident was later found unresponsive. The surveyor confirmed that the stairwell door alarm was difficult or impossible to distinguish from the loud call light system from much of the unit, and staff reported they could not differentiate the door alarm from call bells, contributing to delayed recognition of the resident’s elopement and forming the basis of the deficiency.
A resident with multiple complex medical conditions was prescribed doxycycline for three days following hospital discharge, but due to an order entry error in the eMAR, only a single dose was administered. The DON confirmed the order was entered incorrectly, resulting in the resident not receiving the full course of antibiotic therapy as prescribed.
The facility did not ensure that kitchen staff followed proper hand hygiene and dish sanitization procedures. A dietary aide handled both dirty and clean dishes without washing hands, and the dishwasher was found to be operating without sanitizer. Required checks of the dishwasher's sanitizing function were not consistently documented, affecting all 77 residents.
The facility failed to properly store, prepare, and distribute food, affecting 71 residents. Observations included expired and undated food items, lack of proper labeling and covering, and absence of thermometers in refrigeration units. Food carts were delivered uncovered, exposing food to air, contrary to facility policies.
The facility failed to maintain a homelike environment, with multiple rooms and shared bathrooms exhibiting peeling paint, holes in walls, and missing baseboards. Eight residents expressed dissatisfaction with these conditions, which were acknowledged by the Maintenance Director as ongoing issues. Despite recognizing the problem, the Maintenance Director hesitated to address it due to pending remodeling plans and lack of a clear policy.
The facility failed to manage and document controlled medications properly, leading to discrepancies in medication counts and potential safety issues. An LPN did not have the incoming nurse sign the accountability log, and there was a lack of an Individual Controlled Drug Administration Record for a resident's Clonazepam. Discrepancies were noted in medication counts, and residents had medications without active orders, improperly stored with pill slots covered with tape. The DON acknowledged the need for proper accounting and disposal of controlled medications.
The facility failed to properly label and store medications for five residents, including insulins and eye drops. Observations revealed opened and undated insulin vials, improper storage of insulin pens, and an undated eye drop container without an active order. The DON confirmed that medications should be stored according to package instructions, and the facility's policy requires adherence to pharmacy recommendations and regulatory guidelines.
The facility failed to assist residents with activities of daily living, including eating and oral care. A resident with Alzheimer's and dysphagia struggled to feed herself due to a soiled mask and lack of staff assistance. Another resident with hand contractures was left unsupervised, resulting in untouched drinks and spilled food. Two residents with oral hygiene needs had unkempt teeth and food residue, despite the facility's policy for daily care. The DON acknowledged the need for staff assistance, but observations showed a failure to meet these standards.
A resident with dementia and other health issues was served thin liquids instead of the prescribed nectar-thickened liquids. The CNA corrected the error after noticing the discrepancy. The facility's policy requires dietary staff to prepare meals according to prescribed diets, with CNAs performing a final check before serving.
The facility failed to provide proper urinary catheter care for two residents, leading to increased infection risk. Staff routinely disconnected and cleaned catheter bags with a vinegar solution, contrary to best practices and without physician approval. This practice was inconsistent with the facility's policy, which contributed to the deficiency.
The facility failed to follow infection control protocols by not wearing PPE for two residents on Enhanced Barrier Precautions. Staff were observed providing care without gowns, despite knowing the requirement for PPE during high-contact activities. Both residents had orders for EBP due to their medical conditions.
A resident with dementia and a history of falls sustained an unwitnessed fall resulting in a femur fracture. The facility failed to conduct required neurological assessments at specified intervals for 72 hours post-fall, as per their policy. The resident's electronic medical record showed a lack of assessments from late morning to midnight on the day of the fall, which was confirmed by the DON.
A facility failed to implement fall interventions for a resident with a history of falls and dementia. The resident was found in bed without floor mats and the bed was not in the lowest position, contrary to the care plan. The DON confirmed the required interventions were not in place.
A resident with an acute injury experienced a delay in receiving a STAT x-ray, which was ordered due to suspected deep vein thrombosis. Despite orders being placed, the x-ray was not performed until over 24 hours later, revealing a fracture. The LPN expected the x-ray to be done the same day, and the NP advised staff to follow up with the x-ray company or send the resident to the emergency department if necessary. The facility's administrator was investigating the delay.
The facility failed to document and communicate visitor restrictions for two residents, leading to a deficiency in maintaining safety. One resident's father, who was verbally aggressive, was not properly restricted in the records, and another resident's son, who brought illegal substances, was not documented as restricted. The facility's policy requires such restrictions to be clearly posted and documented, which was not done.
Failure to Supervise Exit-Seeking Resident and Respond to Ineffective Door Alarms
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise and protect a resident with dementia, poor safety awareness, and known exit-seeking behaviors, resulting in the resident eloping from the second floor through alarmed doors. The resident had diagnoses including Parkinsonism, COPD, dementia, unsteadiness on feet, combined systolic and diastolic heart failure, atrial fibrillation, and cognitive communication deficit. The resident had a documented history of elopement behavior, including an elopement attempt in December shortly after admission, which led to relocation to the second floor and implementation of hourly face checks. An elopement risk assessment identified the resident as at risk for elopement, and the care plan documented the resident as an elopement risk/wanderer with impaired safety awareness and a history of attempts to leave the facility unattended. On the day of the incident, multiple staff members reported that the resident was very agitated, repeatedly stated a desire to go home, and kept going to the elevator, requiring frequent redirection. The LPN notified the DON and the NP, obtained orders for lab work and a UA/C&S, and involved social services to speak with the resident. The resident’s son was contacted and spoke with the resident, after which the resident appeared unhappy and continued to express a desire to go home. Staff, including the LPN, CNA, social services assistant, and activity staff, took turns watching and redirecting the resident, but there was no clear, continuous 1:1 supervision assigned despite the resident’s ongoing exit-seeking behavior that day. The activity aide was told to watch the resident and was positioned near the elevator and then in the dining area, but she did not maintain direct observation of the resident when he moved down the hallway. During a period when the LPN and CNA were performing wound care on another resident, the activity aide allowed the resident to move down the hallway in his wheelchair and did not maintain close supervision. Shortly thereafter, staff realized the resident could not be found. The RN reported hearing a faint door alarm under the loud call light system and discovered the resident’s wheelchair outside the stairwell door, indicating the resident had exited into the stairwell. The surveyor later confirmed that the stairwell door alarm was difficult or impossible to distinguish over the loud call light system from much of the hallway and near the nurse’s station, and that staff on the unit could not differentiate the door alarm from call light bells. The resident’s exit path was reconstructed: he traveled down the hall, through the alarmed stairwell door, descended 14 interior steps, exited through a second alarmed door, went down exterior steps, onto a deck and ramp, crossed the facility parking lot and a busy four-lane street, and continued through an adjacent apartment complex parking lot, where he was later found unresponsive. EMS documentation and staff interviews indicated that staff believed the resident had left the facility approximately 30–40 minutes before EMS was called, confirming a significant lapse in effective supervision and response to the alarmed exits. The surveyor’s observations and staff interviews demonstrated that the facility did not ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for this resident. The alarm system on the stairwell door was not reliably audible over the existing call light system, limiting staff’s ability to promptly detect and respond to the resident’s use of the exit. Staff assigned to monitor the resident did not maintain continuous observation despite his known elopement risk and active exit-seeking behavior, and there was confusion among staff about their monitoring responsibilities. These combined factors allowed the resident to leave the secured floor, exit the building through alarmed doors, and travel a considerable distance off facility property before being located, constituting the basis for the cited deficiency.
Antibiotic Order Not Followed Due to Medication Entry Error
Penalty
Summary
The facility failed to ensure that an antibiotic was administered as ordered for one resident. The resident, who had multiple diagnoses including pneumonia, major depressive disorder, osteoporosis, severe protein calorie malnutrition, hypothyroidism, chronic obstructive pulmonary disease, and other conditions, was discharged from the hospital with instructions to receive doxycycline 100 mg daily for three days. However, the electronic Medication Administration Record (eMAR) showed that the order was incorrectly entered as a one-time dose rather than a daily dose for three days. As a result, the resident received only one dose of doxycycline instead of the full prescribed course. The Director of Nursing confirmed that the order was entered incorrectly and that only a single dose was administered, contrary to the hospital discharge instructions and facility policy for safe medication administration.
Failure to Sanitize Dishes and Ensure Hand Hygiene in Kitchen
Penalty
Summary
The facility failed to ensure proper kitchen sanitation practices, specifically regarding the use of the dishwasher and hand hygiene among dietary staff. On observation, a dietary aide was seen unloading clean dishes, loading dirty dishes, and then handling clean dishes again without washing hands in between, which could lead to cross contamination. Additionally, the sanitizer bucket connected to the dishwasher was found to be empty, and test strips confirmed that no sanitizing agent was present in the dishwasher at the time of inspection. The dietary manager acknowledged that the dishwasher should be checked three times daily to ensure proper function and sanitizer levels, and that handwashing is required when moving from dirty to clean dishes. Record review revealed that the facility's dishwasher sanitizer check sheet had missing entries for several meal periods, indicating that required checks were not consistently performed. The facility's policy requires dish machines to be checked prior to meals and mandates handwashing before handling clean dishes after touching dirty ones. The infection control nurse confirmed the importance of proper dish sanitization to prevent the spread of foodborne illnesses and gastrointestinal viruses. These failures applied to all 77 residents in the facility.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and distribute food in a manner that would prevent foodborne illnesses, affecting 71 residents who consumed food from the kitchen. During an initial tour of the kitchen, several deficiencies were observed in the dry food storage area, including expired tomato juice, and various food items such as mashed potatoes and tortillas that lacked 'received on' or expiration dates. Additionally, an opened box of instant food thickener and long grain rice were left exposed to air without 'opened on' dates. The milk refrigerator lacked a thermometer, and undated milk was served to residents despite staff acknowledging the absence of dates. The kitchen cooler contained staff personal items and uncovered food items like juice cups, cheese, bologna, and cut vegetables, all without proper dating or covering. Further inspection revealed improper storage in the kitchen freezers, with raw pork chops stored above tator tots, and various undated and uncovered food items such as sausages, pancakes, and chicken. A second freezer contained improperly covered and undated cooked enchiladas, corn, and ice cream with a broken lid. Food carts delivered to dining halls were uncovered, exposing trays and open cups to air. The facility's policies on food receiving, storage, and preparation were not adhered to, as evidenced by the lack of proper labeling, dating, and covering of food items, as well as the absence of functioning thermometers in refrigeration units.
Facility Fails to Maintain Homelike Environment Due to Peeling Paint and Structural Issues
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as observed during a survey. Multiple rooms and shared bathrooms were found with peeling paint, holes in the walls, and missing baseboards. These conditions were noted in the rooms and shared bathrooms of eight residents, all of whom expressed dissatisfaction with the state of their living environment. The residents' cognitive statuses varied, with some being moderately impaired and others cognitively intact, yet all were aware of and concerned about the environmental deficiencies. The Maintenance Director acknowledged the ongoing issues with the facility's physical environment, including paint and wallpaper peeling, holes in walls, and missing baseboards. Despite recognizing the problem, the Maintenance Director expressed hesitation in addressing these issues due to potential future remodeling plans, which were pending approval from corporate. The lack of a clear policy or immediate plan to rectify the environmental deficiencies contributed to the ongoing neglect of the residents' right to a safe, clean, and homelike environment.
Failure to Properly Manage and Document Controlled Medications
Penalty
Summary
The facility failed to properly manage and document controlled medications for several residents, leading to discrepancies in medication counts and potential safety issues. During an observation, it was found that a Licensed Practical Nurse (LPN) did not have the incoming morning nurse sign the accountability record log for controlled medications, and there was a lack of an Individual Controlled Drug Administration Record log for a resident's Clonazepam medication. Additionally, discrepancies were noted in the medication count for Clonazepam, with missing signatures for tablets removed on specific dates. The facility's Shift Change Accountability Record for Controlled Substances also showed multiple omitted nurses' signatures. Further observations revealed that residents had medications such as Hydrocodone and Lorazepam in their possession without active orders, and these medications were improperly stored with pill slots covered with tape or band-aids. The Director of Nursing acknowledged that all controlled medications need to be accounted for and disposed of appropriately when discontinued or not used. The facility's policy requires controlled substances to be signed out upon dispensing, with a maintained count by nurses of the off-going and oncoming shifts, and any irregularities reported to the Director of Nursing.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly label and store medications for residents receiving insulins and eye drops, affecting five residents. During an observation of medication storage, it was found that a resident's Levemir insulin vial was opened and undated, and another resident's Humulin R insulin vial was open and dated beyond the discard date. Additionally, a resident's Fiasp insulin vial was stored at room temperature despite instructions to refrigerate until opened. Another resident's insulin pens and vials were opened, unbagged, and stored in a multi-resident container, and a resident's Latanoprost eye drop container was open and undated, with no active order for the medication. The Director of Nursing acknowledged that insulin and eye drop medications should be stored according to package instructions and that multi-dose medications should be labeled when opened and discarded as indicated. The facility's policy on medication storage, dated March 2021, states that medications should be stored in accordance with pharmacy recommendations and regulatory guidelines. These observations indicate a failure to adhere to proper medication storage and labeling practices, potentially compromising medication safety administration.
Failure to Assist Residents with ADLs in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance to residents requiring help with activities of daily living, specifically in eating, oral care, and grooming. Resident 57, who has multiple diagnoses including Alzheimer's disease and dysphagia, was observed struggling to feed herself due to a soiled surgical mask and lack of consistent assistance from staff. Despite her need for substantial to maximal assistance with eating, she was left unsupervised multiple times, and her oral hygiene was neglected, as evidenced by overgrown facial hair and unkempt teeth. Resident 1, also diagnosed with Alzheimer's disease and hand contractures, was observed with untouched drinks and difficulty feeding herself due to her hand splints and a soiled surgical mask. Although she required supervision and assistance with eating and drinking, she was left unsupervised, resulting in spilled food and untouched beverages. Her care plan indicated a dependency on staff for all activities of daily living, including feeding. Residents 28 and 26, both with significant medical conditions affecting their ability to perform oral hygiene, were found with unkempt teeth and food residue. Despite the facility's policy requiring daily oral care, these residents were not adequately assisted, leading to a buildup of plaque and food residue. The Director of Nursing acknowledged the expectation for staff to assist residents with their daily living activities, including feeding and oral hygiene, but the observations indicated a failure to meet these standards.
Failure to Provide Correct Consistency of Liquids
Penalty
Summary
The facility failed to provide the correct consistency of liquids for a resident with an order for nectar-thickened liquids. The resident, identified as R60, had multiple diagnoses including dementia, muscle weakness, and respiratory infection, and required setup assistance for meals with an altered diet necessitating thickened liquids. On January 7, 2025, a Certified Nurse Assistant (CNA) served R60 lunch with drinks that were of thin liquid consistency, contrary to the nectar-thickened liquid requirement noted on the resident's meal ticket. The CNA acknowledged the error and corrected it by thickening the drinks after being prompted. The Director of Nursing (DON) confirmed that dietary staff are responsible for preparing meal trays according to prescribed diets, and CNAs are expected to perform a final check before serving meals to residents. The facility's policy on meal service emphasizes the importance of ensuring the accuracy of prescribed diets, including diet type, texture, and fluid consistency. The failure to adhere to these procedures resulted in the resident being served the incorrect type of liquids, which could potentially lead to complications such as choking and aspiration pneumonia.
Improper Urinary Catheter Care and Increased Infection Risk
Penalty
Summary
The facility failed to provide proper urinary catheter care for two residents, R44 and R67, as observed during a survey. For R44, a CNA reported changing the catheter bag from a hanging bag to a leg bag and cleaning the bags with a vinegar and water solution, despite the bag being labeled as sterile and not to be re-sterilized. The RN confirmed this practice, which was instructed during an in-service by the Infection Preventionist. The Nephrology Nurse Practitioner advised against disconnecting the catheter system due to increased infection risk, yet the facility continued this practice without physician approval. For R67, the urinary bag was observed on the floor and later placed under a blanket by a CNA. The CNA stated that the urinary bag is disconnected, cleaned with a vinegar solution, and hung to dry daily, with the cleaned bag from the previous shift being reattached. The LPN confirmed this routine, which involves switching between two bags every couple of weeks. The Infection Preventionist acknowledged that the practice of disconnecting and reusing bags increases infection risk, yet it was the facility's standard procedure. The Director of Nursing stated that the urinary bag is disconnected and cleaned twice daily to maintain cleanliness, although this practice was not approved by the facility's Medical Director or Urologist, nor was there a physician's order for it. The facility's policy on Foley catheter management indicated a different cleaning procedure, which was not being followed. This discrepancy in practice and policy contributed to the deficiency in providing appropriate catheter care and preventing urinary tract infections.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols by not wearing appropriate Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). On January 8, 2025, a Restorative Aide/CNA was observed in a resident's room without wearing a gown, despite the resident being on EBP. The aide provided incontinence care, assisted in changing clothes, and transferred the resident from the bed to a wheelchair without the required PPE. The resident had multiple diagnoses, including hemiplegia, hemiparesis, and dementia, and had an order for EBP since December 30, 2024. Similarly, another CNA was observed on the same day in a different resident's room without wearing a gown while transferring the resident and changing a catheter bag. This resident had diagnoses including Parkinson's disease and Alzheimer's disease and had an EBP order since April 18, 2024. Both staff members acknowledged the requirement to wear gowns and gloves for residents on EBP, especially during high-contact activities such as transferring and incontinence care. The facility's policy from December 2019 mandates the use of gloves and gowns for such activities, yet these protocols were not followed, leading to the deficiency.
Failure to Complete Post-Fall Assessments
Penalty
Summary
The facility failed to complete ongoing assessments for a resident who sustained a fall with injury. The resident, who had a history of repeated falls and impaired cognition due to dementia, was at high risk for falls and dependent on staff for care. After an unwitnessed fall from bed, the resident was initially assessed and found to have no immediate complaints of pain or obvious injuries. However, the resident later complained of left leg pain, and an X-ray revealed a proximal left femur fracture. Despite the injury, the resident's family did not want hospitalization, and the resident remained in the facility with orders for pain management and follow-up with an orthopedic physician. The facility's protocol required neurological assessments immediately after a fall and at specified intervals for 72 hours post-fall. However, the resident's electronic medical record showed a lack of post-fall assessments from late morning to midnight on the day of the fall. The Director of Nursing confirmed that no neurological or 72-hour post-fall assessments were completed during this period, which was a deviation from the facility's Neurological Assessment policy. This policy outlined specific intervals for monitoring key neurological checkpoints, which were not adhered to in this case.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident, who had sustained a recent fall with injury, had appropriate fall interventions in place. The resident, identified as R2, had a history of repeated falls and was at high risk due to impaired cognition related to dementia. R2 was dependent on staff for care and had previously fallen out of bed, resulting in a fracture. The care plan for R2 included keeping the bed in the lowest position and providing floor mats on the sides of the bed. However, during observations on December 11, 2024, R2 was found in bed without floor mats on either side, and the bed was approximately 4 feet off the ground. The Director of Nursing confirmed that the fall interventions for R2 included frequent monitoring, ensuring the bed was in the lowest position, and placing fall mats on the floor, none of which were in place at the time of observation.
Delay in X-ray Acquisition for Resident with Acute Injury
Penalty
Summary
The facility failed to ensure timely acquisition of x-rays for a resident with an acute injury. On November 27, 2024, a resident complained of pain during care, prompting a CNA to alert the nurse on duty. Despite the administration of pain medication and an assessment by the nurse, no immediate findings were noted. Later, the resident again complained of pain, leading the CNA to inform the nurse, who then involved the DON. Suspecting a deep vein thrombosis, the DON contacted the NP, who ordered a venous doppler and a STAT x-ray. However, the x-ray was not performed until the following morning, over 24 hours later, revealing a fracture in the resident's right tibia/fibula. The delay in obtaining the x-ray was noted by the LPN who was on duty during the day shift on November 27, 2024. She expected the x-ray to be completed that evening, but it was not done until the next day. The NP, who assessed the resident later that day, instructed the nursing staff to follow up with the x-ray company and indicated that the resident should have been sent to the emergency department if the x-ray could not be performed promptly. The facility's administrator acknowledged the delay and was investigating the cause. The facility's policy requires laboratory and diagnostic testing to be performed according to the order, with oversight by the DON or a designee, but this protocol was not followed in this instance.
Failure to Document and Communicate Visitor Restrictions
Penalty
Summary
The facility failed to ensure that restricted visitor information was properly documented and communicated for two residents, leading to a deficiency in maintaining resident safety. For one resident, who had severe cognitive impairment and required total assistance for all activities of daily living, the facility did not have the necessary documentation to restrict the resident's father from visiting, despite verbal instructions and awareness among staff. The father's access was supposed to be denied due to his aggressive behavior, but the information was not present in the electronic medical records or posted at the front desk as required by the facility's policy. Similarly, another resident reported that his son was no longer allowed to visit due to bringing illegal substances during a visit. However, there was no signage or documentation at the front desk to indicate this restriction. The facility's visitation policy allows for reasonable restrictions, including denying access to disruptive visitors, but the lack of proper documentation and communication of these restrictions led to the deficiency being identified during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waukegan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elevate Care Waukegan | 2.2 mi | — | 3 | 0 |
| Waukegan Health And Rehab | 2.3 mi | — | 3 | 0 |
| Alpine Care Of Zion | 4.2 mi | — | 6 | 0 |
| Allure Of Zion | 5.1 mi | — | 16 | 0 |
| Claridge Healthcare Center | 7.4 mi | — | 5 | 2 |
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